Accident Investigation Board (AIB) for the Test Site 9920 Event

SAND2014-2192 P

EVENT SUMMARY

During an explosives test at Site 9920, an individual received an injury to their left hand when the detonator in the test unit fired during troubleshooting.

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• Identify relevant facts

• Determine causes

• Develop conclusions

• Determine needs to

prevent reoccurence

TEAM PRINCIPLES• Maximize the investigation as a

learning experience, not just for Sandia, but for the entire DOE Complex

• Find solutions, rather than blame while respecting individuals

• Review the event using the principles of Integrated Safety Management, Safety Culture, Human Performance Improvement and Engineered Safety

• Demonstrate a Just Culture by looking at the event as a result of a system of interoperable parts, not an individual failure, and find the underlying causes, not just ‘surface’ causes

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JOINT NNSA/SANDIA AIB TEAM

Co-Chairs• Don Nichols• Michael Hazen

AIB Team Lead• Carol Adkins

Technical Advisory Team Lead• Philip Heermann

Support Team

AIB Team – NNSA & Sandia• High-rigor operations

expertise• Human factors• Failure analysis• Explosives• Safety culture• Causal analysis• Accident investigations

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TECHNICAL ADVISORY TEAM (TAT)Conducted scientific and engineering analysis and provided technical expertise• Review and understand the design• Determine potential failure paths

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CORE CAUSES① Failure to effectively

implement “safe by design” intent

② Insufficient WP&C of Test Operations

③ Lack of integration and understanding of the project

④ Differing safety culture maturity levels

DIRECT CAUSEThe direct cause of this accident was a

failure in the test device, from mechanical disturbance or electrostatic discharge,

which caused an unexpected detonation.

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1: FAILURE TO EFFECTIVELY IMPLEMENT “SAFE BY DESIGN” INTENT

Design group did not analyze the development and testing cycle of the

device, make the device as safe as they could, and

require it to be treated as unsafe while engineered

safety protocols were being confirmed.

high probability of a high-consequence event with this design

“BORN UNSAFE”

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Fireset Design• Recognized that safety of the

system is inherent in the system design, not the design of individual components.

• Made safety recommendations to other component designers, such as the use of the shorting plug.

• Designed in safety features, such as the LED light.

Explosive Assembly• Applied engineered safety

principles when installing the detonator into the test unit.

• Understood the technical basis by learning enough about the test unit to apply three controls to ensure energy would not reach the capacitor.

• Exhibited defense in depth by assuming the detonator would initiate anyway; used a blast shield to protect the worker.

ENGINEERED SAFETY IN DESIGN

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2: INSUFFICIENT WP&C OF TEST OPERATIONS

The operations group accepted and then executed a job that their existing hazards analysis and operating procedures did not address, without

analyzing the hazard, identifying controls & implementing controls.

AUGUST DECEMBERJULY

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3: LACK OF INTEGRATION AND UNDERSTANDING OF THE PROJECT

The design and testing teams did not interact in a

systematic, comprehensive and acceptable manner to develop/deploy adequate layers of defense against unrecognized hazards.

Project Team Perception

Operations Team Perception

Systems integrator?

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4: DIFFERING SAFETY CULTURE MATURITY LEVELS

Sandia’s diverse workforce has varying levels of safety practice maturity. Typical approaches to advancing the

maturity of safety culture have not been sufficiently tailored to reach all individuals in the workforce,

according to their individual needs.

People who don’t realize they need it

People who think they “get it,” but don’t

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LESSONS LEARNED FROM THE AIB REVIEW

① Maximized learning opportunities - Used a joint review format led by senior Federal and Laboratories personnel.

② Inclusion of management in learning process - Allowed senior managers to attend end-of-day meetings.

③ Conclusions with solid technical basis - Used a Technical Advisory Team.

④ Inclusion of staff in learning process - Involved staff in the discovery process and conducted a small engineering review with the project team and an operations review with test personnel.

⑤ Increased buy-in and personalization - Discussed the results of the review in small group settings with the personnel directly involved.

SANDIA’S APPROACH• Small group safety discussion led by Laboratory President to

all levels of management• AIB corrective actions addressed by line organizations• JONs implementation owned by executive leadership

Themes:1. Effectiveness of implementation/execution2. Extent of condition review3. Independent assessment of implementation4. Safety culture

• Engage the External Advisory Board – focus on safety culture and validate the implementation of Engineered Safety

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Key activities

• Inclusion in the mid-year individual performance review of safety expectations.

• Completion of Corporate implementation of “Work Planning and Control Criteria for Safe Design and Operations” (Sept. 30, 2014)– Apply principles of engineered safety– Application throughout the lifecycle of work

• Management Assurance Review Process